Acute respiratory diseases
All of the diseases presented
below have signs of respiratory distress. Cerebral hypoxia, congenital heart
disease, and metabolic aci-dosis can induce respiratory distress (suspect if
CXR is normal).
•
Caused
by delayed clearance/absorption of lung fluid after birth.
•
Presents
within 4hr after birth. Common after elective CS. CXR: shows streaky perihilar
changes and fluid in lung horizontal fissures.
•
Treatment:
supplemental O2. Consider nasal CPAP and antibiotics.
•
Spontaneously
resolves within 24hr.
•
Caused
by aspiration of infected amniotic fluid.
•
Associated
with prolonged rupture of membranes (PROM), chorioamnionitis, foetal hypoxia.
•
Usually
group B streptococci, Escherichia coli,
other Gram –ve bacteria, listeria, chlamydia.
•
Presents
in first 24hr. CXR: patchy shadowing and consolidation.
•
Respiratory support: antibiotics (benzylpenicillin, or
ampicillin if listeria, and
gentamicin) after septic screen; chest physiotherapy.
•
Prognosis: depends on severity and associated
sepsis or persistent pulmonary
hypertension of newborn (PPHN).
•
5% of
term infants with meconium-stained liquor develop MAS.
•
Hypoxia
results in gasping and meconium passage in
utero, a combination that leads to aspiration. Meconium aspiration inhibits
surfactant, obstructs the respiratory tract, and induces pneumonitis.
•
Presents
with respiratory distress soon after birth. Associated with pulmonary air leaks
and PPHN. CXR: generalized lung over inflation with patchy
collapse/consolidation +/– air leaks.
•
Prevention: if liquor is meconium-stained,
delivery should be expedited to
prevent further hypoxia and gasping. If baby is apnoeic at birth, visualize the
larynx and suck out any meconium from larynx/trachea. Tracheal suction is not
recommended for vigorous infants.
•
Treatment: supplemental O2;
intermittent positive pressure ventilation
(IPPV) or high frequency oscillatory ventilation (HFOV) if ventilation
required; surfactant; antibiotics (since listeria can cause antenatal meconium
passage); treat any PPHN; consider ECMO if severe.
•
Prognosis: mortality <5%. Survivors do
well, but there is ‘rise’risk of asthma and, if extracorporeal membrane
oxygenation (ECMO) is needed, neurological sequelae.
Commonly secondary to other
respiratory disease (e.g. RDS, MAS) or to assisted ventilation.
Spontaneous pneumothorax occurs in
72% term infants. Incidence is increased in prematurity and respiratory
disease.
•
Features: majority are small, asymptomatic,
and resolve spontaneously. If large,
present with respiratory distress. Tension pneumothorax is life-threatening
(signs: respiratory distress, cyanosis, mediastinal shift away from affected
side, ‘fall’ chest movement and air entry on affected side, transillumination
lights up affected side).
•
CXR: shows ipsilateral translucency,
lack of peripheral lung markings, collapsed
lung (see Fig. 6.4).
•
Treatment: none if asymptomatic. Give O2 as required. If symptoms are severe or worsening, insert chest
drain. In emergency, perform needle aspiration before chest drain.
•
Prognosis: excellent in term infants.
Mortality is doubled in infants with RDS.
Also ‘rise’risk of periventricular haemorrhage in preterms.
Air leak into lung parenchyma
results in small airway and alveolar col-lapse. Follows high IPPV, particularly
in preterm infants with severe RDS or MAS.
• Signs:
respiratory distress; chest
hyperexpansion; poor air entry; coarse inspiratory
crackles.
• CXR:
hyperinflation; ‘honeycomb’
pattern of cystic lucencies/bullae,
generalized or local (see Fig. 6.5).
• Treatment:
high FiO2, low PIP, low
PEEP, fast rate IPPV; HFOV may be
•
superior.
Unilateral PIE: nurse infant with affected side down. In refractory cases
consider selective intubation to ventilate the healthier lung.
• Prognosis:
mortality 25–50%. There is an
increased risk of bronchopulmonary
dysplasia.
Often preceded by asymptomatic
pneumothorax/PIE.
•
CXR: translucency around the heart
extending superiorly; thymus lifted and
splayed from below (‘sail’ sign).
•
Treatment: usually no treatment is required.
Usually occurs with other air
leaks associated with IPPV and can
lead to cardiac tamponade (with quiet heart sounds, hypo-tension, bradycardia,
cyanosis).
•
CXR: translucency around the borders of
a small heart.
•
Treatment: urgent needle drainage inserted
under the xiphisternum.
•
Prognosis: high mortality if symptomatic.
Air can occasionally track into
the peritoneum from a pulmonary air
leak. AXR confirms the diagnosis. Severe abdominal disten-tion could impair
ventilation. Drain if symptomatic.
Usually due to haemorrhagic
pulmonary oedema in VLBW infants. Small bleeds are associated with tracheal
trauma from ETT or suction. It is associated with: PDA, heart failure, PIE,
hydrops foetalis, perinatal hypoxia, sepsis, coagulopathy, fluid overload,
surfactant therapy
•
Rapid
systemic collapse.
•
Profuse
bloodstained fluid welling up from upper airway.
•
Respiratory
crackles on auscultation.
•
CXR. Virtual
‘white out’. Consider echocardiography to detect PDA.
•
rise O2
and ventilatory pressures.
•
Frequent
endotracheal suction.
•
Correct
hypovolaemia and coagulopathy.
•
Consider
blood transfusion.
•
Consider
surfactant.
•
Treat
known associations.
Term infants can accidentally
aspirate a feed. The usual causes are:
•
Swallowing
incoordination, e.g. preterm, neurological disease.
•
Upper
airway or oesophageal disorders, e.g. tracheo-oesophageal fistula,
gastro-oesophageal reflux.
Sudden choking or respiratory
distress during or after a feed, often with excessive milk in the mouth, or
aspiration pneumonia.
CXR:
normal or patchy
collapse/consolidation in the upper lobes.
If well, observe only. If unwell, respiratory
support and broad spectrum
antibiotics are needed. Investigate cause and use gastric or naso-jejunal tube
feeding. Period of IV fluids or feeding may be necessary.
Apnoea can result from any severe
illness.
•
Support
respiration.
•
Investigate
and correct primary cause.
•
Common
below 34wks gestation (incidence ‘rise’as gestation d).
•
Between
episodes the infant is well.
•
Consider
and exclude other diagnoses.
Tactile stimulation, blood transfusion,
continuous tube gastric feeds,
caffeine or theophylline, nasal CPAP, or IPPV.
Short-lived apnoeas appear to
cause no harm and should resolve by
34wks gestation.
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